SCOTTSDALE, ARIZ. – Inflammatory abdominal aortic aneurysms can be treated safely and effectively by endovascular aneurysm repair, though patients with significant hydronephrosis may have worse outcomes, a retrospective study suggests.
The study included 69 patients who underwent either endovascular repair (10 patients) or open surgical repair (59 patients) at the surgeon’s discretion at Mayo Clinics in Minnesota, Florida, or Arizona between 1999 and 2011.
Dr. William M. Stone
Previous case series and meta-analyses have reported mixed results with endovascular aneurysm repair (EVAR), but the current study suggests that EVAR is appropriate management for inflammatory abdominal aortic aneurysms (AAAs), Dr. William M. Stone said at the annual meeting of the Southern Association for Vascular Surgery.
In the study’s EVAR group, eight patients presented with symptoms (80%), including one with rupture. In the open-repair group, 31 patients (52%) presented with symptoms, including 3 with rupture (5%).
Ureteral involvement was seen in 23 patients: 2 patients in the EVAR group (20%) and 21 in the open group (34%). Of these 23 patients, 21 underwent preoperative ureteral stent placement (91%). Thirty-six patients in the open-repair group had suprarenal aortic cross clamps (61%).
All of the EVAR procedures were technically successful, and patients were followed for an average of 34 months. The mean aneurysm size in the EVAR group decreased from 5.94 cm preoperatively to 4.73 cm after EVAR, an average change of nearly 18%, reported Dr. Stone of the Mayo Clinic in Phoenix.
Aneurysm size decreased in seven patients (70%), and did not change in two patients (20%) after EVAR. One EVAR patient was lost to follow-up. Preoperative hydronephrosis in one patient (10%) before EVAR did not change after EVAR, and one patient developed new hydronephrosis after EVAR. No patients in the EVAR group died, developed endoleaks, or needed steroids. Two patients developed atrial fibrillation after EVAR and were treated for it.
The inflammatory rind measured 5.4 cm before EVAR and 2.7 cm afterward on average, a mean change of 50%, he said.
In the open-repair group, surgeons used midline incisions in 52 patients (88%), a left flank approach in 6 patients (10%), and a bilateral subcostal approach in 1 (2%) to repair aneurysms with a mean size of 6.3 cm.
One patient in the open-repair group died postoperatively of a ruptured suprarenal inflammatory aneurysm. Major complications were seen in 22 patients (38%), including renal complications in 5 (8%), ischemic colitis in 2 (3%), and ureteral obstruction that required intervention in 3 (5%). A late anastomotic rupture in one patient in the open-surgery group was repaired by EVAR.
During a mean follow-up of 43 months, 17 patients in the open-repair group were lost to follow-up (28%). All of the remaining patients had resolution of their aneurysm sac. Four patients (7%) received steroids, not to treat the aneurysm but for comorbidities.
Among 12 patients in the open-repair group with preoperative hydronephrosis (20%), the hydronephrosis resolved in 7 of the 12 (58%), remained stable in 4 patients (33%), and worsened in 1 patient (8%). The patient with worsening hydronephrosis underwent ureterolysis. Two patients developed renal atrophy.
Although the retrospective study was small, it appeared to show a trend toward less severe complications in the EVAR group, "which is what we intuitively would have guessed," Dr. Stone said.
Previous data from the EUROSTAR (European Collaborators on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair) registry suggested that inflammatory AAA size decreased by 87% after EVAR, he noted (Semin. Interv. Cardiol. 2000;5:29-33). Aneurysm wall thickness averaged 21 mm preoperatively, 17 mm at intermediate follow-up, and 13 mm with long-term follow-up, which is "consistent with our review," he said.
Patients in the EUROSTAR database had problems with graft limb stenosis that were not seen in the current series, Dr. Stone noted. A ureteral stent and/or ureterolysis were required in 18% of the EUROSTAR patients who underwent EVAR. The rate of ureteral "entrapment" (inflammation around the ureters) improved from 45% to 27% after EVAR.
Courtesy of Dr. William M. Stone
A preoperative CT scan shows an inflammatory abdominal aortic aneurysm.
In a previous meta-analysis of data on 46 patients in 14 studies, EVAR decreased aneurysm size in most patients, with a median decrease of 11 mm. Periaortic fibrosis decreased in 52%, was unchanged in 42%, and progressed in 7% (J. Endovasc. Ther. 2005;12:560-7).
A separate meta-analysis of 56 studies with 1,120 patients compared EVAR with open repair of AAA, and found 1-year all-cause mortality rates of 2% with EVAR and 14% with open repair (Eur. J. Vasc. Endovasc. Surg. 2009;38:291-7). Periaortic fibrosis decreased in 65% of the EVAR group and in 73% of the open-repair group. Hydronephrosis regressed in 38% of the EVAR group and in 69% of the open-repair group.